A case of blunt thoracic aortic injury requiring ECMO for acute malperfusion before TEVAR

Abstract

BackgroundBlunt thoracic aortic injury (BTAI) is associated with a high mortality rate and the paradigm of treating patients with BTAI currently favours thoracic endovascular aneurysm repair (TEVAR) if possible. In BTAI, lethal malperfusion caused by a pseudoaneurysm has rarely been reported. We present the first report of a successful case in which a pseudoaneurysm causing the infrequent occurrence of lethal malperfusion and subsequent acute severe ischaemia in the distal portion of the thoracic descending aorta was overcome by veno-arterial extracorporeal membrane oxygenation (VA ECMO) as a bridging therapy until the initiation of TEVAR.Case presentationAn adult woman was transferred to our emergency room after injuries sustained by falling from height. Her vital signs were unstable on admission. CT examination revealed the multiple injuries: traumatic subarachnoid haemorrhage, severe unstable pelvic fracture, and a grade III injury of the thoracic aorta. We made the decision to perform TEVAR after external fixation and transcatheter arterial embolization (TAE) for the pelvic injury. During preparations for TEVAR, her lower limbs rapidly felt cold, and her blood lactate level and serum potassium rapidly increased. By the clinical data and ultrasonography and lower extremity Doppler, we diagnosed severe ischaemia in distal portion of the descending aorta caused by a pseudoaneurysm proximal to the descending thoracic aorta. Because we still had not prepared for TEVAR, we immediately started VA ECMO until TEVAR could begin. After the initiation of VA ECMO, her lactate and potassium levels could be controlled. Under VA ECMO support, she underwent TEVAR. After inpatient rehabilitation, she was discharged home without neurologic sequelae.ConclusionsVA ECMO could be an important, less-invasive treatment as a bridging therapy for acute severe malperfusion syndrome until TEVAR is initiated for BTAI.

Selective Arterial Catheterization as a Bridging Therapy for Blunt Traumatic Aortic Injury With Intraperitoneal Organ Malperfusion

“…We were unable to perform immediate TEVAR in this case, and open surgery for aortic repair was unsuitable owing to risk factors. Although the introduction of extracorporeal membrane oxygenation could be an option for temporary improvement of ischemia, it was not administered in this case because of the risk of rupture [ 4 ]. We decided that the optimum strategy to save the patient's life was to first improve organ ischemia, followed by exploratory laparotomy, and finally TEVAR.…”

Early Clinical Diagnosis and Treatment of Traumatic Aortic Injury Caused by Thoracic and Abdominal Injuries: A Series of Four Cases with Literature Review

“…It is reported that more than 75% of TAI patients die before they are transferred to a medical center, and more than half of the remaining patients die within 24 hours [ 6 ]. The main causes of early death in patients with TAI include insufficient tissue perfusion and hemodynamic instability [ 7 , 8 ]. With the development of imaging technology and equipment, blunt aortic injury has been detected in an increasing number of patients with abdominal or chest injury.…”